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Dental Management of Patients Taking Anticoagulant
Drugs Outside a General Hospital Setting
NHS Tayside Integrated Dental Service Local
Guidance
July 2013 Version (v2)
Compiled by:
G Sime
Senior Dental Officer
Reviewed by:
S Adair
M Curnow
P Currie
G Elliott
W Esler
W George
I Hay
S Hutcheon
R Kerr
A Macdonald
H Macritchie
S Manton
P McLoughlin
A Neilson
G Ogden
S Shepherd
Senior Dental Officer
Clinical Dental Director
Consultant Cardiologist
Senior Dental Officer
Senior Dental Officer
Senior Dental Officer
Senior Dental Officer
Consultant Cardiologist
Consultant Haematologist
Senior Dental Officer
Deputy Clinical Dental Director
Consultant in Restorative Dentistry
Consultant Maxillofacial Surgeon
Consultant in Oral Surgery
Professor of Oral Surgery
Lecturer in Oral Surgery
REVIEW DATE
(Due) April 2013
(Due) July 2014
BY WHOM
See above
COMMENTS
Completed July 2013
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Background
This guideline has been composed to offer guidance, standardisation of care
and information to practitioners caring for patients who attend the
anticoagulant clinics throughout the Tayside Area. Dental patients who are
taking oral anticoagulants (or injected low dose Fragmin - up to 5000 units)
may undergo surgical procedures safely in primary care so long as their
treatment is planned and managed appropriately.
Patients taking anticoagulants are at increased risk of significant prolonged
bleeding following dental extractions/surgery (defined as bleeding for more
than 12 hours post-operatively which cannot be controlled by local measures
alone.) However, published evidence suggests that with appropriate local
management of haemostasis, at the time of treatment, by suturing and
placement of haemostatic material, these risks should be minimal for most
patients taking the anticoagulants covered in this guidance.
Discontinuation of anticoagulant therapy carries significant risks of morbidity,
sometimes with a fatal outcome, from thromboembolic complications. There
is some evidence that there is a “rebound” effect of discontinuing oral
anticoagulants, which increases the daily risk for patients above the baseline
risk for patients with similar pathology who have never taken an
anticoagulant.
Therefore it is considered that, in the majority of clinical situations, the risks
of discontinuing oral anticoagulant therapy outweigh the minimal benefits of
reduced post-operative bleeding. Dental management of these patients is
based on good operative technique, use of local measures to minimise
bleeding and the avoidance, whenever possible, of changes to the patient’s
anticoagulant regime.
Aim of Guideline
To ensure that such patients are managed in line with current evidence, this
guideline is consistent with the advice given in the following documents.
- BNF No. 62 (September 2011)
- The NHS National Patient Safety Agency poster, “Managing patients who
are taking warfarin and undergoing dental treatment” (2009)
- North West Medicines Information Centre documents, “Surgical
Management of the Primary Care Dental Patient on Warfarin.” (Revised
2007) and “Surgical Management of the Primary Care Dental Patient on
Antiplatelet Medication.” (Revised August 2010)
- British Committee for Standards in Haematology, “Guidelines for the
management of patients on oral anticoagulants requiring dental surgery.”
(Due for revision 2011)
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Who should use this Guideline?
All dental staff involved in the management of patients prescribed oral
anticoagulant drugs and who are undergoing dental surgery.
Patients Unsuitable for Dental Management in Primary Care
Patients who have an INR greater than 4.0, or who have very erratic INR,
should not undergo any form of dental procedure, other than those from the
“safe” list below, without consultation with the clinician who is responsible for
maintaining their anticoagulation. The anticoagulant dose may be adjusted
prior to the procedure, at the discretion of this clinician or elective dental
procedures from the “risk of significant bleeding” list below deferred.
The following medical problems may affect coagulation and clotting:
liver impairment and/or alcoholism
renal failure
thrombocytopenia, haemophilia or other disorder of haemostasis
current course of cytotoxic medication.
Patients with any of these conditions, who also take anticoagulants, should be
discussed with a Senior Dentist before undertaking a procedure which carries
a significant risk of bleeding.
Dental Management for Patients Taking Oral Anticoagulant Drugs
Many dental procedures do not involve a significant risk of bleeding and therefore no
special measures are required when treating patients who take an oral anticoagulant
drug.
These procedures are:
- Simple restorative treatment
- Supragingival scaling
- Local anaesthesia by buccal infiltration, intraligamentary or mental block
- Impressions and other prosthetics procedures.
Procedures which carry a risk of significant bleeding and for which the dentist needs
to consider the management of the patient in relation to their anticoagulant therapy
are:
- Local anaesthesia by inferior alveolar or other regional nerve blocks or lingual or
floor of mouth infiltrations.
- Subgingival scaling and Root Surface Instrumentation (RSI).
- Crown and bridge preparations
- Extractions
- Minor oral surgery
- Periodontal surgery
- Biopsies.
- Incision and drainage of swellings.
- Endodontics (In the case of endodontics, clinicians may wish to consider the
need for special precautions on a case by case basis.)
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Planning Treatment & General Guidance Notes
-
If the patient is on a finite course of anticoagulant, consider delaying
elective treatment which may cause bleeding, until the anticoagulant drug
has been discontinued.
If emergency treatment is necessary and the INR is unknown
ON WEEKDAYS
-
Arrange an urgent INR test via the patient’s GMP or usual INR test
provider.
If the INR is 4.0 or less, proceed with treatment required.
If the INR is > 4.0 phone OMFS at Ninewells and confirm the referral in
writing via a letter given to the patient to take with them.
AT WEEKENDS
-
Contact the on call Senior Dental Officer to confirm the need for urgent
treatment and the need for an INR.
-
If both dental treatment carrying a risk of bleeding and an INR reading
are required, the patient should be referred directly to the OMFS
Department via the duty Senior House Officer, so that the INR and the
dental treatment can be carried out in hospital.
GENERAL GUIDANCE
-
There is no indication for routinely prescribing antibiotics for patients who
take oral anticoagulants. Where antibiotics are required, it should be
noted that many antibiotics interact with coumarins and ideally the INR
should be rechecked four days after starting a course of antibiotics.
-
Morning appointments, earlier in the week allow any post op bleeding to
be dealt with in the working day and before the weekend.
-
Local anaesthetic solutions containing a vasoconstrictor should be used
unless contraindicated on other medical grounds. An aspirating syringe
must be used for all local anaesthetic injections.
-
For subgingival scaling, a small area should be scaled first, to assess the
amount of bleeding, before instrumentation of larger areas is carried out.
It may be necessary to complete a full mouth scaling over several visits.
-
Extractions should be restricted to a maximum of three teeth per visit
with only a single tooth being extracted at the first visit, when possible, to
assess the amount of bleeding.
-
All extractions should be completed as atraumatically as possible.
-
Sockets should be gently packed with haemostat and sutured, ideally
with resorbable sutures, at the time of extraction.
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Post-operative management/care instructions for extractions and
surgery
The patient should be advised to rest for 2-3 hours post-operatively, to allow
the clot to stabilise and local anaesthetic to wear off. The patient should be
given the standard post-operative advice verbally and in writing.
Appropriate telephone contact details should be issued to the patient, in
writing, and the patient should know how to obtain advice and/or help both in
and out of hours, if bleeding occurs.
In addition the following (modified) advice regarding analgesics should be
given.
 For post-operative pain control, paracetamol is the safest painkiller.
Non-steroidal anti-inflammatory drugs such as aspirin, ibuprofen,
voltarol, ponstan etc. must be avoided.
 If paracetamol alone is not sufficient to manage pain, the patient
should consult their doctor for advice on pain relief
Dental Management Strategy for Patients Taking Oral
Anticoagulants
Step 1 - Assess the dental procedure to be performed for risk of bleeding.
(If no significant bleeding risk – proceed with dentistry.)
Step 2 - Assess the anticoagulation status of the patient.
Step 3 – Follow detailed guidance below and proceed with dentistry, delay
dentistry pending advice from the patient’s physician or refer for specialist
dental / oral surgical management.
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Primary Care Dental Management of Patients Taking Oral
Anticoagulant Drugs in Current Use
Vitamin K Antagonists (Indirect effect on the production of clotting
factors.)
WARFARIN, ACENOCOUMAROL (Nicoumalone, Sinthrone) PHENINDIONE
The anticoagulant effect of these drugs is measured by the International
Normalised Ratio (INR). Because of the nature of the action of these drugs it
takes several days for a change in the dose of the drug to produce a change
in the INR reading. These drugs interact with many other medications so it
always wise to check for possible interactions before prescribing for patients
taking a vitamin K antagonist.
For most patients the target INR is in the range of 2.0 to 3.0. Occasionally
patients have higher target ranges of 2.5 to 3.5 or 3.0 to 4.5.
DENTAL MANAGEMENT
INR check as close to the time of extraction as is practical, preferably within 24
hours before treatment. For patients with a stable INR of < 4.0 who have maintained
3 months within the range +/- 0.5 of target INR and no readings >4.0, an INR
reading taken within 72 hours prior to treatment may be accepted.
For patients with unstable INR readings, or where there has been an INR
reading of >4.0 in the last two months, the pre-operative INR reading should be
obtained in the 24 hours prior to the dental procedure.
Is the INR in the therapeutic?
range and  4.0 ?
YES
Proceed to extraction
NO
If the INR is found to be >4.0, the patient should be
referred back to the clinician managing the
anticoagulation, and the dental treatment postponed.
If the INR is < 4.0 but outside the target therapeutic
range, proceed with dental procedure but refer the
patient back to the physician for possible amendment
of the anticoagulant dosage.
If the treatment cannot be postponed (e.g. emergency
extraction or incision and drainage) the patient should
be referred to the Oral and Maxillofacial Surgery
Department.
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Anticoagulants that do not require regular blood test monitoring RIVAROXABAN (Xarelto) and APIXABAN (Eliquis)These are oral drugs which
are direct inhibitors of activated factor X. Rivaroxaban is the predominant
factor Xa inhibitor used in Tayside but the advice is the same for both agents.
For some patients this drug is used for only 2- 6 weeks following elective
knee and hip replacement surgery and such patients should rarely present for
treatment while still taking the drug and most dental work should be delayed
until after this period. It is also used longer term for treatment of DVT and
Pulmonary Embolism and in some patients with atrial fibrillation. In clinical
trials the anticoagulant effect was demonstrated to be equivalent to a patient
on warfarin with a target INR of 2.0 - 3.0. The drug has a relatively short
half-life (9 hours) so the clotting status returns to normal within 24 hours if
the drug is discontinued. Due to predictable pharmacokinetics and use
of fixed doses of this agent there is no routine blood test monitoring
required and the INR is not sensitive to the anticoagulant effect in
these patients.
DABIGATRAN ETEXILATE (Pradaxa)
This is an oral drug which is a direct thrombin inhibitor. It is used in some
patients with atrial fibrillation. In clinical trials the anticoagulant effect was
demonstrated to be equivalent to a patient on warfarin with a target INR of
2.0 - 3.0. It also has a relatively short half-life (13 hours) so the clotting
status returns to normal within 24 hours if the drug is discontinued (unless
the patient has developed renal failure). Due to predictable
pharmacokinetics and use of fixed doses of this agent there is no
routine blood test monitoring required and the INR is not sensitive
to the anticoagulant effect in these patients.
DENTAL MANAGEMENT
-
-
No pre-operative testing required.
For all extractions, scaling etc. Proceed without altering the drug regime.
Multiple extractions and surgical procedures are considered safe for
patients continuing to take these anticoagulant drugs. When practical,
however, the number of teeth to be extracted at a single visit should be
limited to 3-4 teeth and it is advisable to assess the extent of bleeding
after the extraction of the first tooth. (There is an approximate 1:10,000
risk of stroke, per day, in patients with atrial fibrillation without
anticoagulant therapy).
For patients with a prosthetic valve or other device in place,
consult the cardiologist for advice. (It is very unusual –
approximately 5-6 patients across Scotland - for a patient with a
prosthetic valve to be placed on these drugs rather than warfarin. As
each patient will need to be managed in an individual manner it is vital
that their cardiologist is contacted for advice.)
-
For patients on short courses of anticoagulant, post orthopaedic surgery,
delay any elective treatment until the patient is recovered. For emergency
treatment in such patients, consult the orthopaedic surgery team before
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proceeding. (Rationale for this relates to the risk of post operative
infection of the recently placed prosthetic joint, rather than to bleeding
risk.)
-
Where a patient taking these drugs presents with a post operative
haemorrhage, contact the Haematology Department for advice.
(Other than the lack of a requirement for pre-operative INR testing,
the dental management for patients taking Rivaroxaban, Apixaban
and Dabigatran is the same as would be the case for a patient taking
Warfarin, who has a stable INR with readings consistently less than
4.0.)
Anti-Platelet Drugs
ASPIRIN
CLOPIDOGREL (Plavix)
DIPYRIDAMOLE (Persantin, Persantin Retard)
ASPIRIN/DIPYRIDAMDOLE COMBINATION (Asasantin Retard)
PRASUGREL (Efient)
TICAGRELOR (Brilique)
The anti-platelet drugs may be used alone or in combination – usually aspirin
plus one other – or occasionally an anti-platelet drug may be used in
combination with a coumarin.
DENTAL MANAGEMENT
-
-
For patients taking only aspirin the risk of excessive bleeding is minimal.
Proceed following the general guidance notes above.
For patients on a single anti-platelet drug or dual aspirin/dipyridamole
therapy (Asasantin Retard) there is a risk of increased bleeding but this
may not be clinically significant. Proceed following the general guidance
notes above.
For patients taking Aspirin in combination with Clopidogrel or Prasugrel,
consult the patient’s cardiologist before planning dental interventions.
These patients may have a history of unstable cardiac problems and/or
recent cardiology interventions such as stent placement. If a patient
has had a stent placed and is taking dual anti platelet therapy
then this should only be stopped in cases of extreme clinical
emergency and only after discussion with the invasive
cardiologists. This might mean postponing dental work until the period
of dual anti-platelet therapy (DAPT) is over.
FOR ANY OTHER COMBINATION OF ANTIPLATELET/
ANTICOAGULANT MEDICATION – CONSULT THE PHYSICIAN
MANAGING THE PATIENT’S CARE BEFORE PROCEEDING.
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Injected Anticoagulants
DALTEPARIN (Fragmin)
Low dose fragmin (5000units od), used for prophylaxis of Deep Vein
Thrombosis, is equivalent to warfarin with target INR of 2-3 and could be
managed as such.
Due to the short half life, the fragmin could be omitted 24 hours prior to an
elective extraction if there are particular concerns regarding bleeding.
Higher therapeutic doses may cause bleeding problems and it would
NOT be appropriate to proceed with extractions etc. whilst the
patient is on such a treatment regime. Patients who require such a
regime are almost certainly at high risk of a thrombotic event and
there would be serious concerns regarding discontinuation of the
fragmin regime. Where possible, dental work should be delayed.
If dental treatment cannot be delayed, then the management of the
patient must be discussed with the physician in charge of the
anticoagulant treatment.